Quality and Safety of Hospital Care for Children from Spanish-Speaking Families with Limited English Proficiency

In the Literature

Effective communication between patients and providers is critical to high-quality health care. When patients are children, parents or guardians must step in to ensure a full and open exchange of information. When parents do not speak English, however, children may not receive high-quality—or even safe—care.

As part of a larger project supported by The Commonwealth Fund and directed by Lisa Simpson, a research team led by Christina Bethell conducted focus groups to examine communication-related hospital quality and safety issues for children from Spanish-speaking families with limited English proficiency (LEP). These focus groups also assessed the salience of a parent survey to evaluate these issues within hospitals caring for children.

According to, "Quality and Safety of Hospital Care for Children from Spanish-Speaking Families with Limited English Proficiency" (Journal for Healthcare Quality, May/June 2006), parents, providers, hospital staff, and quality improvement (QI) professionals agree that language and cultural differences lead to communication issues that can have a pervasive, negative impact on the quality and safety of care children receive, but disagree about what exactly needs to change.

To identify priorities and strategies, the researchers conducted 12 focus groups with 72 individuals at children's hospitals in South Florida and Southern California. The groups consisted of: Spanish-speaking parents with limited English proficiency (LEP) whose children had recently been hospitalized; physicians, nurses, or other hospital staff who came into direct contact with families; and QI professionals.

Problems and Priorities
During the focus group discussions, 12 overarching themes emerged about how language and cultural differences contribute to communication problems and, consequently, how these differences affect quality and safety of care. (See box for examples of participants' comments.) No one theme, however, was identified by all three groups.

Participants disagreed on which identified problems should be top priorities. For example, parents ranked "doctors do not respond quickly" as their highest priority issue arising from language and cultural differences that impacts the quality and safety of hospital care for their children. Providers ranked this issue last. Providers and QI professionals, meanwhile, were more likely to cite language and cultural problems that lead parents to be less forthcoming with information or hesitant to seek care in the first place. Less than one-quarter of parents identified this as a top priority. However, parents, providers, hospital staff, and QI professionals all perceived that language and cultural differences have a negative effect on the quality and safety of hospital care for children.

Strategies for Improvement
All three focus groups agreed on four specific areas for improvement:

• Hospitals should provide more medically trained interpreters through each phase of the hospital stay and ensure continuity of interpreters for families and providers. Telephone translation is insufficient: it is impersonal, does not take into account body language, and prevents demonstration of use of equipment and medication dosing.
• Improving communication skills should be a universal focus.
• Providers and staff must be patient with families and encourage and help them to be more empowered and to speak up.
• Parents should receive a checklist and information form to record their questions in preparation for the arrival of interpreters.

Barriers to Implementing Improvements
The authors acknowledge fundamental barriers to implementing the strategies for improvement. In particular, many providers and QI professionals recognize that serious communication issues exist yet often do not acknowledge the effect these problems can have on quality and safety of care. Additionally, there is a need to adopt a more rigorous, outcome and systems-oriented definition of quality where quality is "meeting patients' needs and getting good outcomes," not simply "doing your best" with available resources. There is also the commonly held, but often erroneous, belief among hospital professionals that existing language services—lay interpreters and telephone assistance—are sufficient.

Conclusions
Findings from the focus groups led the researchers to seven main conclusions:

1. All aspects of quality can be affected by language and cultural differences.
2. Preventing and addressing communication problems requires involvement from all hospital staff and members of the community.
3. Divergent perspectives among parents, providers, hospital staff, and QI professionals about the nature of communication problems and responsibility for action may limit progress.
4. To understand and track improvements, more measurement of needs and problems may be necessary.
5. Parents are key partners in ensuring communication and quality and safety of care.
6. Communication problems are not limited to Spanish-speaking LEP patients.
7. Hospitals can take action now.

"The common and distinctive perceptions obtained from parents, health care providers, hospital staff, and QI professionals," say the authors, "enrich our understanding of the specific issues that arise in practice and help to lay the groundwork for formulating improvement strategies."